shock shock general surgery orientation medical student lecture series dr. peter meade
TRANSCRIPT
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ShockShock
General Surgery OrientationGeneral Surgery OrientationMedical Student Lecture SeriesMedical Student Lecture Series
Dr. Peter MeadeDr. Peter Meade
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SHOCK
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SHOCK
Burning building Desert
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SHOCK
Lack of Oxygen Delivery
Low blood pressure
Decreased perfusion of tissues with Oxygen
Inflammatory Response
Cell Damage
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SHOCKLack of Oxygen Delivery
(Hypoperfusion)
Cellular Damage
Inflammatory Response
Hypoperfusion causes Inflammation
Inflammation causes Hypoperfusion
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What causes….
SHOCK
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SHOCK
Most common forms in surgery:
Hypovolemic
Septic
Cardiogenic
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SHOCK
Lack of Oxygen Delivery
(Hypoperfusion)
HypovolemiaBleeding / Hemorrhage
Vomiting
Pancreatitis
Burns
Trauma
Hypoperfusion causes Inflammation
Inflammation causes Hypoperfusion
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SHOCK HYPOVOLEMIC
hemorrhagic
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SHOCK HYPOVOLEMIC
Non-hemorrhagic fluid losses
Open wounds Burns- incredible fluid losses !
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SHOCK:SEPTIC: Endotoxins from bacteria = Shock!
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SHOCK
Lack of Oxygen Delivery(Hypoperfusion)
Septic
Septicemia, Endotoxins, Vasodilatation, pneumonia,
urinary tract infection, dead intestine, necrotic tissue
Hypoperfusion causes Inflammation
Inflammation causes Hypoperfusion
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SHOCK CARDIOGENIC
Pump Failure Cardiogenic Shock
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SHOCKLack of Oxygen
Delivery(Hypoperfusion)
Cardiogenic
Acute Myocardial infarctionAortic or mitral valve dysfunction
DysrhythmiaCardiac contusion
Massive Pulmonary embolismCardiac Tamponade
Congestive Heart Failure
Hypoperfusion causes Inflammation
Inflammation causes Hypoperfusion
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SHOCKLack of Oxygen Delivery
(Hypoperfusion)
Cellular Damage
Inflammatory Response
Hypoperfusion causes Inflammation
Inflammation causes Hypoperfusion
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Inflammatory Response
• Vasoconstriction
• Vasodilation
• Capillary leak– Nitric Oxide, PG2, kinins, histamine serotonin
• White Cells/ Polymorphonuclear cells– Phagocytosis: proteases, Interleukins
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Inflammatory Response
Platelet Activation
PDGF
TGF-B
WBC Products
P-seletin
E-selectin
ICAM 1
WBC Proteases
IL-1, IL8
TNF
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The Inflammatory ResponseIt can be like using a machine gun to kill a fly on the wall….
You might get the fly, but the wall gets hit too!
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Hypoperfusion
• Anaerobic glycolysis
• Lactic Acidemia– Low bicarbonate– Low pH
• Multisystem Organ Failure
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Krebs Cycle
36 ATPs
Anaerobic glycolysis
2 ATPs
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Burning glucose without Oxygen = lactic acidosisBurning wet sticks = smoke
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TREATMENT OF SHOCK
Treat the primary cause
“Source Control”
Hemorrhagic / Hypovolemic– Stop the bleeding– Replace blood loss, volume
Septic– Drain the abscess– Treat with antibiotics, volume, pressor agents
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Starling Curve
• Preload
• Contractility
• Afterload
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Starling Curve
• Preload
• Contractility
• Afterload
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Hypovolemic Shock
Loss of circulating blood volume (Plasma)
Normal Blood Volume:
- 7% IBW in adults
- 9% IBW in children
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Hypovolemic Shock
Hemorrhagic shock (3 categories)
1. Compensated:– 0-20% of blood loss
– Blood pressure is maintained – increased vascular tone – increased blood flow to vital organs
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Hypovolemic Shock
The body’s response:
Compensated shock Baroreceptor mediatedvasoconstriction
Increased epinephrine, vasopressin, angiotensin
Results in:TachycardiaTachypneaLowered pulse pressureSlightly lowered urine output
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Hypovolemic Shock
The Organs who win:BrainHeartKidneysLiver
The Organs who lose:SkinGI tractSkeletal Muscle
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Hypovolemic Shock
But why
The body will make whatever adjustsments it can to maintain….
AdequateCardiacOutput
Brain and heart perfusions remain near normal less critical organ systems stressed by ischemia..
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Hypovolemic Shock
2. Uncompensated:
20-40% loss of blood volume
Decrease in BP
Tachycardia
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Hypovolemic Shock
The body’s response:
Uncompensated shock
vasoconstrictive mechanisms
FAIL to maintain systemic perfusion pressure.
• Increased cardiac output• Increased respiration• Sodium retention
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Hypovolemic Shock
3. Lethal exsanguination: 40% loss of blood volume
Profound hypotension and inability to perfuse vital organs
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Hypovolemic Shock
Volume Resuscitation ~ What are my goals?
1. Rapid Responder– Give 500cc-1 Liter crystalloid rapid
improvement of BP/HR/Urine output– < 20% blood loss– Surgery consult
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Hypovolemic Shock
Volume Resuscitation ~ What are my goals?
2.Transient Responder– 500cc-1 Liter crystalloid improves briefly then deteriorates
– 20-40% blood loss– Continue crystalloid infusion +/- Blood– Surgery consult
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Hypovolemic Shock
Volume Resuscitation ~ What are my goals?
3. Non Responder– Give 2 Liters crystalloid/ 2 units Blood no
response– > 40% blood loss– STAT Surgery consult!
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Hypovolemic Shock
Is my volume resuscitation adequate/inadequate?
Urine output Vital signsSkin perfusionPulse OximetryAcidemia
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Septic Shock
exaggerated endogenous inflammatory response to invasive infection leading to:
-circulatory collapse
-multiple organ failure
-death
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Septic Shock
Mortality
over 35% (sepsis with hypotension)
45% (sustained septic shock)
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Septic ShockManagement:Identify and treat the infectious source
eg – simple incision & drainage? Exploratory laparotomy?
Amputation?
Volume resuscitation
Restoration of perfusion pressure (may need pressors!)
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Cardiogenic Shock
Acute hypotension
low cardiac output
inadequate LV outflow
Poor end organ perfusion!
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Cardiogenic Shock
Causes most likely to see on the surgery wards:Causes most likely to see on the surgery wards:
Acute MIAcute MI
Arrhythmia (A. fib)Arrhythmia (A. fib)
Cardiac Contusion Cardiac Contusion
Cardiac TamponadeCardiac Tamponade
Massive Pulmonary EmbolismMassive Pulmonary Embolism
Decompensated Congestive Heart FailureDecompensated Congestive Heart Failure